5502 W. Buckeye, Suite 100 • Phoenix, AZ.
• 602.466.5016
Partner Agency Annual Renewal
1. Review Partner Agency Handbook and Data Reporting Information.
2. Complete and submit the application (doc and scanned signed versions) via email .
3. The Diaper Bank reserves the right to decline applications based on a variety of criteria and community need.
4. During the application process a site visit and/or agency interview may be requested.
Agency Information
Legal Name of Agency:
Other Names Used by the Organization:
Mailing Address (If PO Box, also list location of principal office):
City/State/Zip:
Service Location Address(es):
Main Phone: Fax:
Website:
Program name using diapers/incontinence items:
Program contact person and title:
Email: Phone number w/direct extension: Mobile:
Executive Director’s Name:
Email: Phone number w/direct extension:
Agency Mission:
Brief Program Description. (500 character limit, no attachments):
EIN Number:
Has there been any change in your nonprofit status (as defined by the IRS), your corporate status (as defined by the AZ Corporation Commission), your organization’s name, or your mission/vision?
If yes- please attach supporting documentation.
No change
If you do not file a 990 annually please attach a copy of your independent audit or current MOU.
How will the diapers be used?
On-site residential program
Daycare
Supplies for families as part of case management
Emergency supplies for families
Other (please explain)
Page 6 of 8
5502 W. Buckeye, Suite 100 • Phoenix, AZ.
• 602.466.5016
Does Agency budget for purchasing incontinence supplies for agency use? No Yes
Do you currently turn away clients due to a lack of diapers? No Yes
Are you willing to be a Open Partner Agency, allowing individuals who need emergency diapers? No Yes
If yes, for individuals seeking diapers please list: direct url where info regarding getting diapers from your agency can be found, location(s) that participate, and corresponding phone numbers.
Does your agency receive donated diapers from other agencies or diaper banks? No Yes from
What is the minimum percent of your clients served with diapers who:
Fall below the Federal Poverty Level:
Low Income (less than twice the Federal Poverty Level, includes falls below poverty line):
Receive casework (30+ days) that helps clients become self-sufficient:
What does casework typically look like for clients who receive diapers from your agency and how does this help them towards self-sufficiency? (2000 character limit, no attachments.)
(Optional) Is there anything else you would like to tell us about your agency? (Perhaps any upcoming changes, info that will help us understand your agency better, what your client base is like, etc. Questions do not go here, instead please call. 2000 limit, no attachments.)
Projected Estimation of Program Use for the 2017 Calendar Year:
- The average number of diapers you will provide per diaper user at each distribution: diapers
- The average number of diapers you will distribute each month: diapers
- The average number of unique diaper users you will serve each month: users
- Number of unique diaper users annually (count each person only one time): users
- Number of duplicated diaper users served annually (count each user each time they receive diapers from you): users
- Number of potential diaper users on waiting list for diapers: Average time on waiting list is: months
- Average length of time diaper users are active in program: months
% of Total Users by Geographic Location / % of Total Users by Race Ethnicity
Maricopa County / White/Caucasian
Pinal County / Hispanic/Latino
Gila County / Black/African American
Yavapai County / American Indian or Alaskan Indian
Other: / Asian
Other: / Native Hawaiian or other Pacific Islander
Other: / Two or more ethnicities
Other: / Other/Unknown
Other: / Total / 100%
Total / 100%
% of Total Users by Age
% of Total Users by Disability / < 1 year old
With Disabilities / 1 year old
Without Disabilities / 2 years old
Total / 100% / 3 - 4 years old
5 - 6 years old
% of Users or Guardians with Military Status / 7 - 18 years old
Veteran, Active Duty, or Reserve / 18 - 55 years old
Non-military / 55+ years old
Total / 100% / Total / 100%
% of Homeless Diaper Users / % of Diaper Users Receiving
Homeless / Case Management (30+ days)
Not Homeless / Emergency Distribution
Total / 100% / Total / 100%
Projected Annual Diaper/Incontinence Supplies
Page 6 of 8
5502 W. Buckeye, Suite 100 • Phoenix, AZ.
• 602.466.5016
Please estimate diaper needs for a 12 month period to aid Diaper Bank in planning and budgeting activities. Accuracy is important. Estimates are for individual diapers - not package.
Does your agency have programs that need to meet clients complete diaper need due to clients living on site in a nursery/shelter or are homeless? Yes No Mix
If no: Allot children to receive a maximum of 50 diapers per month or 30 pull ups while in your program, as according to NDBN guidelines. Allot adult diaper users to receive 30 diapers per month. For example, if you had a average newborn baby that would be in the program from Jan-Dec you would allot: 50 nb diapers, 150 size 1 diapers, 150 size 2 diapers, and 250 size 3 diapers for the year.
If yes: Allot diaper users to receive enough diapers to meet their full need while in your program.If users are typically in your program for 3 months, allot their need only for 3 months (not for 12).Howmanydiapers.com is a great resource for predicting how many diapers a child under 3 years of age will need over any chosen length of time for all sizes. The average baby needs 2k diapers (size nb-3) their first year, 1.8k (size 3-4) their second year, 1.5k (size 4-5) their third year.
If Mix: Number of unique children in program with shelters/etc: monthly, annually
Number of unique children in program without shelters/etc: monthly, annually
Number of unique adult users in program with shelters/etc: monthly, annually
Number of unique adult users in program without shelters/etc: monthly, annually
Follow the allotment guides described above for each type of program.
Page 6 of 8
5502 W. Buckeye, Suite 100 • Phoenix, AZ.
• 602.466.5016
NB:
Size 1: Adult Small:
Size 2: Adult Medium:
Size 3: Adult Large+:
Size 4: TOTAL Incontinence Supplies:
Size 5:
Size 6: Overnight diapers
2T-3T: Feminine Products
3T-4T:
4T-5T:
TOTAL Child Diapers:
Collaborative Partnership
The provision of diaper supplies is a cooperative effort between the Diaper Bank and our Partner Agencies for the 2017 calendar year. Partner Agency agrees to complete the following by the corresponding deadlines this calendar year to ensure the community can continue to receive this service and will email the Diaper Bank to notify as each item is completed, or agency will pay a penalty. Due to the extensive amount of time spent trying to track collaborative agreement expectations we are asking that you email us when each item is complete with the details. Our financial resources are extremely limited and the more money that we spend on administrative needs means the less diapers we can provide.
Administration Fee Choose 1 of the following. To be received by the Diaper Bank no later than July 1st, 2017.
$50 Agency serves 25 or less unique diaper users annually & gets only 1 distribution which has annual allotment (instead of quarterly)
$200 Agency serves 35 or less unique diaper users monthly & more than 25 unique users annually
$400 Agency serves 36-100 unique diaper users monthly & no more than 300 unique users annually
$600 Agency serves 100-500 unique diaper users monthly & no more than 1000 unique users annually
$750 Agency serves over 1,000 unique diaper users monthly
Choose a minimum of 1 from the following:
Volunteer at the Diaper Bank at least: hours, completed before 2018.
Provide a financial contribution of , completed before 11/1/2017.
Acknowledge & tag the Diaper Bank Facebook page each distribution with picture(s).
Communicate about the Diaper Bank, diaper need, encourage supporters to donate dollars for diapers or hold drives for the Diaper Bank in one of your newsletters with our logo and url, completed by 11/2017.
Notified by email with an attached copy of the full newsletter from agency program contact email address w/message stating this item has been completed.
Place a link to DiaperBankAZ.org & our logo on a main page by 3/1/2017. Notification must include a direct link where logo can be seen.
Host a diaper drive for the Diaper Bank through your agency, completed by 10/1/2017.
Please know that by choosing this item, these diapers are to benefit the Diaper Bank on behalf of your agreement and all diapers raised during the drive are to be counted and delivered to the Diaper Bank. The more diapers we receive and distribute the more assistance we may be able to get from grants for more diapers. For more details please see page 11 of the Partner Agency Handbook.
Additional ideas for collaborative partnership? (beyond word of mouth) to be completed by is:
Tell us about upcoming events! We would love to know about your events so we may attend, participate, sponsor, and/or share on social media.
Partner Agency Agreement
The provision of diapers and supplies is a joint effort between The Diaper Bank and our Partner Agencies. Partner Agencies agree to the following to ensure the community can continue to receive this service.
(Executive Director and Program Administrator, please initial at the end of each item)
1) To follow all procedures and requirements as outlined in the Partner Agency Handbook. ______
2) The recipient agency certifies that it is a nonprofit 501(c)(3) social service agency, a religious organization in good standing, or other governmental agency providing social services to individuals or families in need and that it has included documentation of such status along with this executed Agreement. ______
3) Provide supplies to clients in a conscientious manner. No products obtained from the Diaper Bank may be sold, traded or bartered, or be used for fund raising, auctions or raffles. Items may only be used to provide services to the clients of the recipient agency free of charge, and may not be used as gifts to staff or volunteers. The recipient agency agrees to make every effort to avoid duplication of services with other agencies and to avoid providing diapers to clients who will sell, exchange, or barter with the diaper supplies. ______
4) The recipient agency will provide supplies received from the Diaper Bank without discrimination on the basis of race, color, national origin, ethnicity, gender, religion, age, disability, political beliefs, sexual orientation, marital or family status; and further to certify that any assistance directly or loosely linked to diapers and supplies does/will not require attendance at religious services or classes, nor is there any inducement of conversion to a faith group, institution or cause in order to receive assistance. ______
5) Supplies from the Diaper Bank of Central Arizona are to be used as one part in a broader effort by the recipient organization to assist those in need. At least 90% of the clients who receive diapers will be provided with some level of case management (30 days minimum) to the individual or family so they may have the opportunity to work towards self-sufficiency. At least 80% of clients who receive diapers fall below the federal poverty line. Further, items provided by the Diaper Bank will not be redistributed to another agency for use. Please refer that agency to the Diaper Bank. ______
6) To comply with Diaper Bank data reporting requirements and to notify us of any changes in your organization’s contact information and mission. It is the agency's responsibility to train any new program contacts and to provide them with a copy of the partner agency handbook, your agency's application, in-kind receipts, statistical tracking materials, how to report data, etc. The Diaper Bank is happy to train new program contacts for the partner agency for a fee of $25. It is the agency's responsibility to track and report all requested statistics accurately based on records and no estimations. Partial data reporting ("Monthly Tracking Form") is required before each distribution in order to participate. Agencies who fail to turn in data reporting by deadlines or whose reporting is deemed inaccurate or unreasonable will not be allowed to participate in the corresponding distribution. The Diaper Bank is happy to set a session for $25/per session to reclarify terms, explain the forms, and/or help agencies understand why their tracking was deemed unreasonable. Full data reporting (demographics, number of users, diapers distributed, etc) is due at the end of the year. Refer to ''Data Reporting Information" for more information regarding what items need to be tracked. ______
7) To comply with the Collaborative Partnership in a timely manner and to notify the Diaper Bank as activities are completed. Agency agrees to make a financial contribution to the Diaper Bank that is equal to the administrative feeamount this calendar year if this is not fulfilled. ______
8) The agency, it's staff, volunteers, or other personal are not to refer clients or other staff to visit or call the Diaper Bank directly for supplies or questions. The Diaper Bank is not a direct social service agency but a support agency. It is the responsibility of the recipient agency to ensure all its staff is aware of all provisions and to answer any questions they have. ______
9) The recipient agency acknowledges that Diaper Bank receives diapers and supplies donated by others; that Diaper Bank often receives donations of loose diapers or opened packages of diapers; that Diaper Bank may purchase diapers and supplies; and that Diaper Bank is donating the diapers and supplies to the recipient agency with no consideration received. Although Diaper Bank believes, to its best knowledge, that these diapers and supplies are safe, Diaper Bank has not inspected these supplies for safety or other matters. It is the responsibility of agency personnel to inspect the diapers and supplies they provide to their clients. ______
10) Partner Agencies hereby indemnify, defend and hold harmless the Diaper Bank, their affiliated agencies, officers, directors, contractors, agents, employees, and volunteers from any and all liabilities, loss, damages or expenses from all claims, demands, and actions (including but not limited to attorney's fees) out of or in connection with the use or handling of these diapers and supplies by the recipient agency, its employees, its clients, its volunteers, and anyone to whom it involved with the donated supplies and Partner Agency hereby forever releases and discharges the Diaper Bank from any and all claims for any known, unknown or future damages. ______